fracturi masiv facial - curs 3
DESCRIPTION
chirurgieTRANSCRIPT
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FRACTURI ale MASIVului FACIALFracturi ale etajului mijociu al fetei
Fracturi ale maxilarului
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Masivul facial• Constitue un bloc osos unic pluricavitar,
compus di 13 oase, sudat la baza craniului,etajul anterior si mijlociu, itr-un unghi de 45 grade fata de planul de la Frankfurt
• Cu baza cranilui realizeaza un veritabil ansamblu biomecanic,anatomic,anatomopatologic si clinic indisociabil
• Aceste elemente justifica termenul de complex cranio-facial a caror structuri asigura rigiditatea intregului ansamblu
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Masivul facial(Termen propus de Le Fort 19o1)
• Mesivul facial inglobeaza 13 oas• 6 perechi:• maxilar(pivotul principal)• malar• lacrimal• nazal• palatinal• cornetul inferior• 1 nepereche • vomerul• Unite prin sinostoue intr-un bloc osos unic sudat la baza
craniului intr-un unghi de 45%
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Masivul facial-bloc osos unic suspendat la baza craniului
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Arhitectura masivului facial
Zone maxima rezistentaStilpi de rezistenta Grinzi de rezistenta
Zone de minima reziste Zone de slaba rezistena clasate de
LeFort joase,mijlocii,inaltePlanseul orbitar
Peretele anterolateral al sinusului
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Masivul facial• Structura arhitecturala :
• Zone de maxima rezistenta• - Stilpi de rezistenta • pilierul anterior( canin sau nazo-maxilar• pilierul lateral (malar sau zigomato-maxilar)• pilierul psterior( pterigoidian) • -Grinzi de rezistenta:• grinda inferioara• grinda mijlocie • grinda superioara• Teoretic sunt zone rezistente.Daca forta impactului
este mare stilpii se fractureaza ca picioarele unei mese lovite din lateral
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Masivul facial datorita fragilitatii peretilor si a structurii cavitare este asemanat cu o cutie de
chibrituri asezata sub si in fata unei carcase dure
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Stilpi de rezistenta
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Stilpi de rezistenta
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Grinzi de rezistenta
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Stilpi si grinzi de rezistenta
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Masic facial• Zone de minima rezistenta ( Le
Fort)
• Zona inalta (intercraniomaxilara)
• Zona mijlocie(traverseaza masivul facial pe sub malare)
• Zona inferioara (traverseaza masivul facial imediat deasupra palatului dur)
• Peretii cavitatilor masivului facial
• Complexul nazo-etmoido-maxilar
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Linii de slaba rezistenta trnsversale descrise de LeFort in 1901
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Radigrafic complexul cranio-facial se prezinta ca un bloc cu 3 etaje
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Etiologie
• Barbati detin un procent de circa 20%
• In raport cu fracturile de mandibla cele de masiv detin un procent de circa trei ori 1 la mai mic.Raportul este de 1 la 2 sau de 1 la 3
• Cauza este ca mandibula este mult mai expusa la traumatisme decit masivul facial
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Factori etiologici • Agresiunea unei altei persoane• Accidente de circulatie • Accidente de munca• Caderi accidentale• Lovituri accidentale• Accidente de sport • Muscaturi de animale• Raniri cu arme de foc• Explozii accidentale• E.t:c.
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Mecanism de producere• Fracturile se produc ca rezultat al impactului dintre: • efector :• intensitatea energiei cinetice• forma corpului contondent• consistenta corpului contondent• suprafata de impact• unghiul de inclinatiea actiunii corpului
contondent• distanta de plecare a corpului contondent.• receptor• grosimea partilor moi acoperitoritoare• structura sheletului osos(arhitectura osoasa)
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Mecanism de producere
• Mecanism direct
• Leziunile se localizeaza la locul de impactizare
• Mecanism indirect• Fractura se propaga la distanta de
locul de impactizare
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Mecanism direct
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Mecanism direct
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Mecanism indirect
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Mecanism indirect
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Anatomie patologică
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Sunt antrenate in leziunea traumatica trei elemente anatomice
• 1 Partile moi• Echimoze , hematoame , excoreatii, plagi
• 2 Leziuni traumatice dento-parodontale• Fracturi dentare coronare,radiculare • Luxatii dentare
• 3 Scheletul osos al masivului facial• Se produc frcturi:• totale• partiale• • •
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Fracturi partiale
• Procesul alveolar ( Ocluzo- faciale)
• Tuberozitate ( Ocluzo-faciale)
• Bolta palatina
• Apofiza ascendenta
• Peretele anterior al sinusului maxilar
• Arcada zigomatica
• Os malar –unele forme
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Fracturi totale
• Ocluzo-faciale
• Centro-faciale
• Latero-faciale
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Fracturi: ocluzo-faciale, centro-faciale, latero-faciale
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Fracturi totale ocluzo-faciale1 Fracturi transversale(Orizontale –Le-Fort)• Transversale joase( Le fort I)• Transversale mijlocii (Le Fort II)• Trnsversale inalte( Le Fort III)2 Fracturi verticale• Mediana • Paramediana3 Fracturi mixte4 Fracturi complexe dizlocatii multiple ale masivului facial fracturi cominutive ale masivului facial
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Fracturi transversalejoase, mijlocii,inalte
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Tipuri de fracturi transversale:joase(A), mijlocii(B) ),inalte(C)
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Fractutra de tip Le Fort iii ,ii si ,i
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Fracturi verticale. Fractura mediana
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Fractura mediana –disjunctie intermaxilara –(tip Lannelongoe)
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Fractura verticala paramediana
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Fracturi mixte
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Fracturi complexe- dizlocatii multiple ale fetei
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Fracturi complexe –Fractura cominutiva a masivului facial
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Fracturi complexe –Dizlocatii multipe ale fetei
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Fracturi centro-faciale
• Fracturi ale oaselor nazale
• Fracturi ale complexului nazo-etmoido-maxilar
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Fracturi centro-faciale .Fractura complexului nazo-etmoido-maxilar
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Fracturi centro-faciale- complex nazo-etmoido-maxilar
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Fracturi centro-faciale. Fractura nazo-orbitara(Convers)
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Fracturi cominutive centrofaciale deschise la tegumente
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Fracturi latero-faciale
• Fracturi ale complexului zigomatic
• Fracturi anterioare
• Fracturi posterioare
• Fracruri anterioare si posterioare
• Fracturi ale peretelui anterior al sinusului
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Fractupa latero-faciala –Fractura anterioara a complexului zigomatic
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Fracturi latero-faciale.Fractura cominutiva malaro-maxilara
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Fracturi asociate. Fractura panfaciala
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Fracturi asociate cu leziuni traumatice la distanta
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Semne şi simptome comune
Inspectie
Palpare
Examene paraclinice
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Semne si simptome clinice comuneExtraoral -Inspectie
• Edem palpebral sau a intregului etaj mijlociu• Echimoze (echimoze palpebrale bilaterale, tip ursulet Panda)• Chemozis bilateral sau unilateral• Hematom difuz sau localizat• Excoreatii• Plagi ale partilor moi intra sau extaorale• Deformatia fetei( prabusire totala sau partiala a fetei( fata in
farfurie, fata plata)• Alungirea etajului mijlociu al fetei• Epistaxis• Discontinuitate osoasa si crepitatii la palpare• Emfizem subcutanat• Largirea distantei intercantale (in fracturi centro-faciale)• Tulburari oculare( exo sau enoftalmie,diplopie,pareza pleoapei
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Edem,excoreatii si inaltarea etajului mijlociu al fetei
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Echimoze palpebrale tip ursulet Panda
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Echimoze multiple si edem facial.Alungirea etajului mijlociu al fetei
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Echimoze palpebrale bilaterale,plaga
cutanata ,prabusirea obrazului
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Prabusirea obrazului-nas in sea
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Prabusirea obrazului-nas in sea
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Echimoze palpebrale,alungirea etajului mijlociu coborirea globului
ocular sting
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Epistaxis si echimoze palpebrale
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Edem,echimoze,epistaxis,alungirea etajului mijlociu al fetei,obraz
aplatizat
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Rinolincvoreea in fracturile complexului etmoido-mxilar
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Largirea distantei intercantale
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Plaga verticala , discontinuitate osoasa ,largirea distantei
intercantale si interpupilare
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Fracturi ale complexului nazo-etmoido-maxilar deschisa la tegumente
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Fractura cominutiva masiv facual deschisa intra-extraoral cu pierdere de substanta
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Plaga verticala labio-genio-palpebrala
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Palparea reliefurilor si mobilitatii osoase anormale
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Palparea extraorala, intraextraorala si intraorala
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Semne si simptome clinice comuneInraoral
• Deformare si discontinuitate osoasa a arcadei dentare si a creastei zigomato -alveolare
• Tulburari de ocluzie(ocluzie inversa sau deschisa frontal,contacte molare premature,ocluzie incrucisata)
• Mobilitate osoasa anormala( maxilar plutitor)• Limitarea deschideri cavitatii orale• Halena fetida din cavitatea orala• Tulburari
functionale :respiratorii,fonatorii,masticatorii ,deglutitie,hipersalivatie
• Retrudarea intregului masiv facial generator de asfixie Intrerupereaa continuitati osoase( inspectie, palpare) Tulburari functionale
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Mobilitate osoasa anormala animatie
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Tulburari de ocluzie.Ocluzie incrucisata
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Echimoze extra si intraorale, .deplasarea intrgului
masiv facial in jos si lateral
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Tulburari de ocluzie.ocluzie deschisa frontal
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Deformarea arcadei dentare datorita fracturi verticale
paramediane
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Palparea intraorala.Se constata denivelare reliefurilor si intreriperea
continuitatii osoase
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Fractura partiala de rebord alveolar
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Fractura cominutiva masiv facial deschisa intraoral
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Retrudarea masivului facial,ocluzie molara prematura ,blocarea cailor
aeriene superoare
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Evolutie
• Datorita bogatei vascularizatii si structuriimajoritar spongioasa poseda un potential de consolidare extrem de rapid
• Calusul fibros se organizeaza in 8-10 zile• Calusul osos dupa circa 20-30 zile(mai
rapid la copii(• ,Mai tardiv se consolideaza la
batrini,politraumatizati,bolnavi tarati,fracturi deschise la tegumente sau intraoral, bolnavi cu igieana orala precara,complicatii inflamatorii.
• Reducerea tardiva prezinta dificultati majore . Se impune reducerea imediata
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Complicatii• Complicatii imediate• 1 asfixia prin:• retrudarea masivului facial spre orofaringe• prezenta corpilor straini• inundatie saguina,saliva,voma, etc.• 2 socul hemoragic• 3 socul traumatic• 4 edemul cerebra
• Complicatii secundare• infectii ale partilor moi,osoase,sinusurilor,orbitelor,retromaxilare
• Complicatii tardive• consolidare vicioasa cu toate consecintele sale • blocarea deschiderii cavitatii orale • comunicari largi buco-nazale ori sinuzale• deviatie de sept nazal
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Tratament .Fracturi de masiv facial fara cele lateo-faciale
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Tratament local
• Tratament de urgenta (provizoriu)
• urgenta vitala imediata( asfixia ,hemoragia nazala sau orala)
• urgenta vitala aminata
• Tratament primar sau definitiv
• Tratament secundar sau de intretinere
• Tratament tardiv al sechelelor
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Hemostaza mecanica.Tamponament nazal
anterior
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Hemostaza mecanica.Tratamentul hemoragiei nazale. Tamponament
nazal anteropsterior
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Tamponament nazal anterior
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Tamponament nazal anterior
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Tamponament nazal posteriorcu balonas si anteroposterior
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Tratament in urgenta imediata.Tratamentul asfixiei
• Reducerea imediata a fracturii• . Anterotrudarea manuala sau instrumentala a
masivului facial. Poate reduce sau stopa si hemoragia
• Reducere si imobilizarea provizorie (ghid: ocluzia dentara):
• intercranio-maxilara, itercranio-mandibulara• intermandibulo-maxilara• Reducere si imobilizare definitiva• ortopedica( intercranio- maxilara, intermaxilara )• chirurgicala chirurgical-ortopedica
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Reducerea manuala a fracturi
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Reducerea instrumentala a fracturii
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Reducere si imobilizare ortopedica provizorie
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Imobilizare de urgenta provizorie intercranio-maxilara.Aplicarea
zabalutei
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Imobilizare de urgenta intercranio-mandibulara. Bandaj mento-cefalic
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Reducere si imobilizare provizorie(istoric)
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Reducere ortopedica .Tractiuni elastice inter-mandibulo-maxilare si intermaxlare
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Tratament ortopedic definitiv . Imobilizare dfinitiva intermaxilara
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Reducere si imobilizare chirurgical-ortopedica
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Suspensii diverse
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Suspensie la osul frontal
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Reducere si imobilizare chirurgicala
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Reducere si imobilizare cu fire de sirma
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Reducere si imobilizare cu placute metalice
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Imobilizare cu placute metalice
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Fracturi latero-faciale
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Clasificare• A Fracturi ale complexului zigomatic
• 1 Fracturi anterioare• a) fracturi totale ale malarului• fracturi incomplete( fisura)• fractura disjunctie maxilo-malara• fractura cominutiva• b) fracturi partiale• fractura rebordului orbitar inferior sau lateral• fractura planseului orbitar
• 2 Fracturi posterioare• Fractura arcadei zigomatice • cu deplasare inV,inU, in trapta ,in sant, • , fara delasare in lemn verde
• 3 Fracturi antero-posterioari
• B Fractura peretelui antero-lateral al sinusului maxilar
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Fractura totala anterioara a compexului zigomatic :Fractura
disjunctie de malar
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Fractura disjunctie a malarului
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Fracturi totale posterioare ale compexului zigomatic
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Fractura arcadei zigomatice
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Fractura partiala a planseului orbitar
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Fractura partiala a planseului orbitar
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Clinica .Fracturi anterioare• Infundarea reliefului malar• Plagi,edem si echimoze unilaterale in zona reliefului malar
fracturat• Tulburai oculare(devierea globului ocular in ax
verical,diplopie ,cecitate, midriaza etc.)• Limitarea deschiderii largi a fantei palpebrale• Tulburari de sensibilitate( hipoestezie infraorbitara)• Epistaxis unilateral• Chemozis unilateral• Dificultati in deschiderea gurii( blocare deschiderii)• Largirea distantei intecantale• Zone dureroase in aria de fractura• Discontinuitate osoasa rebordul orbitar inerior sau lateral• Denivelare in treapta a crestei zigomatoalveolare
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Clinic .Fracturi posterioare
• Echimoze sau excoreatii in zona arcadei zigomatice
• Infundarea reliefului osos daca fragmentele sunt deplasate
• Limitarea miscarilor mandibulare sau chir blocarea lor
• Senzatie dureroasa spontana sau la palparea reliefului arcadei zigomatice
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Echimoză, excoriaţie, chemozis conjunctival unilateral-O.D.
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Fractura disjunctie malar drept deschisa la tegumente prin plaga contuza.Echimoza ,edem silimitarea
miscarilor pleoapei superioare
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Echimoze,excoreatii si plagi in zona malara
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Echimoza si plagi unilaterale.Infundarea reliefului malar Fractura malar drept
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Echimoza si epistaxis unilateral. Fractura malar siting
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Infundarea reliefului malar
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Infundarea reliefului malar,excoreatii si chemozis
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Chemozis,infundarea reliefului malar
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Infundarea reliefului arcadei zigomatice, echimoza,semnul corpului contondent
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Caderea globului ocular.Ligamentul cantal extern deplasat in jos,prin dizlocarea malarului
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Fractura disjunctie malar drept.Deplasarea globului ocular.
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Fractura planseului orbitar.Coborirea globului ocular spre sinus
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Fractura planseului orbitar –caderea globului ocular in sinus
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Coborirea globului ocular
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Fractura disjunctie malar sting.Deplasarea globului ocular in
jos si in afara
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Limitarea vederii in sus din cauza limitarii mobilitatii pleoape superioare
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Evolutie• Consolidarea fracturii se realizeaza repede
dupa 10 -12 zile
• Fracturile fara deplasare se vindeca fara urmari
• Fracturile cu deplasarea fragmentelor daca nu sunt reduse la vreme se consolideaza rapid in pozitie vicioasa ,provocind:
• tulburari fizionomice( infundarea reliefului malar sau zigomatic), ,diplopie ,constrictie de mandibula
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Complicatii
• Imediate: asfixia,socul hemoragic,socul traumatic, edemul cerebral
• Secundare:Infectii ale partilor moi,bonturilor osoase cavitati sinuzale,contaminarea endocraniului cu flora microbiana din fosele nazale
• Tardive:consolidare vicioasa ce conduc la:tulburari de ocluzie,tulburari cosmetice,comunicari buco-nazale,diplopie, hipoestezie ,deviatie de sept constrictie de maxilare,anchiloza extraarticulara coronoido-zigomatica
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Tratamintul fracturilor latero-faciale
• Beneficiaza in toate cazrile de tratament chirurghica
• Scop: - refacerea reliefului malar si arcadei zigomatice ,a rebordurilor orbitare,a planseului orbitar
• - reducerea distopiei cantale laterale si a celei orbitale
• -restabilirea mobilitatii sipozitiei globului ocular
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Tratament
• Reducerea fragmentelor trebue executata cit mai rapid ( in primele 5-6 zile)
• Mai tirziu se ficzeaza in pozitii vicioase. Dupa 10-15 zile reducerea este extrem de dificila
• Fragmentele cu margini neregulate repuse in pozitie anatomica ramin angrenate si nu necesita decit reducereat
• Fragmentele neangrenate necesita imobilizare la bonturile fixe
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Calea de reducere temporala metode Gillies,D .Teodorescu.
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Imobilizare cu placute metalice
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Reducerea si imobilizarea planseului orbitar cu mesa iodoformata intra-sinuzala
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Reconstrucia planseului orbitar cu grefa osoasa
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